NR-302 Health Assessment I - Set 3 - Part 1

Correct Answer: Complete a full assessment of the ache

Pain signals pathology or injury at any age and is never something to tolerate in later years. Minimizing language from the client is a signal to assess more closely, including function, gait, sleep, and mood. Option b is incorrect because agreeing endorses a myth. Painful conditions such as osteoarthritis, osteoporosis, and vascular disease grow more common with age, and every one of them carries a treatment that would otherwise be missed. Option c is incorrect because advising rest before knowing the cause can drive immobility, deconditioning, and falls. Recommending an intervention without an assessment skips the step that would reveal what the hip actually needs. Option d is incorrect because postponing turns an offhand remark into an untreated problem for months. Older adults already underreport, and a nurse who lets the subject drop has removed the one chance she took to raise it.

Correct Answer: Prevention of penetration and fluid loss

The horny layer of the epidermis is waterproof in both directions and blocks organisms from entering. Once extensive burns strip it away, fluid pours out and bacteria walk in, which is why burns kill. Option a is incorrect because vitamin D synthesis happens when ultraviolet B light converts a cholesterol precursor in the epidermis. Losing it raises deficiency risk over months, not the immediate fluid and infection crisis described here. Option b is incorrect because thermoregulation works through dermal vessels widening or narrowing and eccrine glands releasing sweat. Burn clients do lose that control, yet the stem points to leaking fluid and invading organisms instead. Option d is incorrect because perception is the sensory role of the dermis, covering touch, pressure, vibration, temperature, and pain. Its failure sets a client up for unnoticed injury rather than for rapid dehydration and sepsis.

Correct Answer: The first is linear, the second generalised

A streak where a plant brushed the skin is a linear configuration and stays localised to the contact site. A rash covering trunk and both arms is described as generalised in distribution. Option b is incorrect because annular means a ring with a cleared centre, the tinea pattern, and grouped means a tight cluster in one small area. Neither client shows a ring or a cluster. Option c is incorrect because confluent lesions run together into a single mass, as urticaria does, while zosteriform eruptions track one dermatome. A solitary gardening streak matches neither of those patterns. Option d is incorrect because polycyclic describes annular lesions that have merged, and discrete describes separate lesions staying apart, like skin tags. The widespread symmetric rash is better captured by its distribution.

Correct Answer: Pain is referred from the injured spleen

Blood collecting under the left side of the diaphragm irritates it, and the phrenic nerve carries that signal to the left shoulder. Left shoulder pain after blunt abdominal trauma means splenic injury until proven otherwise. Option a is incorrect because a pulled muscle would hurt on movement of that joint and show local tenderness. Treating this presentation as a strain delays recognition of bleeding inside the abdomen. Option b is incorrect because injured nerves generate burning, electric, or tingling sensations along a nerve territory, not a dull ache appearing minutes after a blow elsewhere. No mechanism here damaged the brachial plexus. Option d is incorrect because attributing a new pain to emotion is the reflex that gets serious injury missed. Referral patterns repeat from client to client because segmental nerve supply is the same in everyone.

Correct Answer: Vitamin B twelve is lacking

Folate and vitamin B twelve both enlarge red cells, but only B twelve damages the posterior columns and peripheral nerves. Numbness, an unsteady gait and a beefy red tongue settle the distinction here. Option b is incorrect because folate depletion also enlarges red cells, yet it spares the nervous system completely. Correcting with folate alone would lift the blood count while nerve damage quietly advances, which is the classic trap. Option c is incorrect because iron shortage shrinks red cells rather than enlarging them, and it brings spoon nails, pale conjunctivae and a pale smooth tongue instead of the beefy red one described. Option d is incorrect because missing niacin gives pellagra, recognized by the three signs of dermatitis on sun exposed skin, diarrhea and dementia. Red cell size stays normal and the feet are not numb.

Correct Answer: The hard palate and sclera near the limbus

Bilirubin shows first in the sclera closest to the limbus and on the hard and soft palate, both examined in bright natural light. Palms and soles add support when the finding is uncertain. Option a is incorrect because heavily pigmented body skin masks a yellow cast until bilirubin climbs very high. Waiting for the trunk to change color means missing liver or hemolytic disease for days. Option b is incorrect because conjunctivae and nail beds are the sites chosen for pallor and cyanosis, where reduced or deoxygenated hemoglobin shows. Neither location displays bilirubin as early as scleral and palatal tissue. Option c is incorrect because the yellowish subconjunctival fat gathered near the outer canthus is a normal variant in darkly pigmented clients. Reading it as jaundice produces a false alarm, and the shins tell nothing.

Correct Answer: A food frequency questionnaire

A food frequency questionnaire lists foods and asks how often each is eaten over weeks or months, so it is the method that exposes a food group habitually left out of the diet. Option a is incorrect because the recall covers only the previous day and cannot describe a month of habit. It is fast and needs no literacy, which suits an opening question, not this one. Option b is incorrect because a written diary gives a precise picture of three days only, and recording changes what people eat while they do it. Long standing habit stretches well beyond that window. Option d is incorrect because staff counting trays measures what is served and eaten inside a facility for a day or two. This client lives at home, and the question concerns months of habit.

Correct Answer: Macule, a flat colour change

A macule is solely a colour change: flat, circumscribed, and under one centimetre, so it can be seen but not palpated. Freckles, petechiae, and a flat naevus all fit this description. Option b is incorrect because a papule is solid, elevated, and palpable, rising above the surface as a superficial thickening of the epidermis. The nurse could feel it passing a fingertip across the forearm. Option c is incorrect because wheals come from localised dermal oedema and are raised, irregularly bordered, and short lived. A mosquito bite raises one within minutes and it fades again within hours. Option d is incorrect because a vesicle is an elevated cavity holding free clear fluid, the ordinary blister. Fluid under the surface would lift the skin, and this forearm lesion sits flat.

Correct Answer: Tachycardia, guarding, grimacing, and diaphoresis

Acute pain drives a sympathetic alarm response, so heart rate and blood pressure climb while the client sweats. Guarding the injured wrist and grimacing are the behavioral indicators that accompany that fresh autonomic surge. Option a is incorrect because a slowed pulse with falling pressure reflects a parasympathetic surge seen in severe biliary or renal colic. Skin in that state turns pale and clammy, not flushed and dry. Option b is incorrect because stable readings paired with a blunted expression describe someone whose autonomic system has already adapted over weeks. That picture belongs to persistent pain, not to an injury sustained hours ago. Option c is incorrect because slowness, rigidity, and pulling away from other people develop after months of unrelieved discomfort. A wrist broken this morning has not had time to reshape how the client moves or socializes.

Correct Answer: Edema and scleroderma

Mobility is the ease with which skin rises into a fold. Fluid already filling the intercellular spaces blocks the lift, and the thickened fibrotic dermis of scleroderma binds the skin down. Option a is incorrect because low red cell mass shows itself as pallor, especially in the conjunctivae and nail beds. Reduced oxyhemoglobin changes color rather than the way a fold of skin lifts. Option b is incorrect because fluid loss lowers turgor, so the fold lifts easily and then stays tented on release. That is the opposite of skin that cannot be raised at all. Option d is incorrect because cumulative ultraviolet exposure produces lentigines, wrinkling, and thin fragile tissue. Those changes make skin easier to pinch up, not harder, so mobility rises rather than falls.

Correct Answer: Offer the faces pain rating scale

Cartoon faces carry meaning across literacy and language lines, so this adult can still deliver a self report. The tool is not pediatric only, and pairing it with a qualified interpreter strengthens the assessment. Option b is incorrect because behavioral scoring is reserved for clients who cannot report at all. This client is awake and willing, so replacing their account with the nurse's inference throws away better information. Option c is incorrect because relatives soften, edit, and add their own views of how much medicine a person should take. Language help must come from a qualified medical interpreter, never from the family. Option d is incorrect because grimacing and guarding are supporting detail, not a substitute for what the person having the experience can tell you. Charting behavior alone leaves the intensity question unanswered.

Correct Answer: Give the prescribed analgesic as ordered

The report is the most reliable indicator of pain, and stable vital signs neither confirm nor refute it. Withholding an ordered analgesic because the pulse looks calm delays relief the client already asked for. Option a is incorrect because repeating a measurement that cannot verify pain buys half an hour of continued suffering. Vital signs are a cue to assess, not a test the client must pass. Option b is incorrect because an entry describing comfort contradicts what the client just said and stays in the record for every later shift. Documentation that signals doubt changes how the next clinician treats this pain. Option c is incorrect because nothing here is actually inconsistent. Heart rate and blood pressure return to baseline within hours to days while pain continues, so calling the provider adds delay without adding information.

Correct Answer: Begin it before conception and continue through pregnancy

The neural tube closes in the first three to four weeks, often before a woman knows she is pregnant, so folic acid is taken daily by any woman who could conceive and continued through pregnancy. Option a is incorrect because confirmation usually comes after a missed period, by which time the tube has already formed. Starting then misses the window that the supplement exists to protect. Option b is incorrect because the second trimester is when energy needs climb by a few hundred calories a day. Neural tube protection is long past by then, so the timing serves a different purpose. Option d is incorrect because folic acid is recommended for every woman capable of becoming pregnant, whether or not anemia exists. Waiting for a low blood count ties prevention to a condition that may never appear.

Correct Answer: Plaque, coalesced papules forming a plateau

Papules coalescing into a raised, plateau-like surface larger than one centimetre form a plaque, and psoriasis on extensor surfaces is the classic example. Elevation separates it from a flat patch. Option a is incorrect because a patch is purely a colour change larger than one centimetre, flat and impalpable. Vitiligo and chloasma qualify; anything the fingertips can feel rising has left that category. Option c is incorrect because tumours run to several centimetres and extend deep into the dermis, like a lipoma or a haemangioma. These elbow lesions are broad and superficial rather than deep masses. Option d is incorrect because wheals are fleeting, arising from localised dermal oedema and fading within hours, as after a mosquito bite. Psoriatic lesions persist for months and carry heavy scale.

Correct Answer: The percentage of usual weight lost decides significance

Ten pounds off a three hundred pound frame is a small share of usual weight, while the same loss from a much lighter client crosses the threshold that signals significant depletion over time. Option a is incorrect because raw pounds carry no meaning until they are set against the weight the client carried when well. Identical losses represent very different depletion in a large and a small body. Option b is incorrect because today's number describes where the client stands, not how far they have fallen. Nutritional risk lives in the change over a defined interval, which a single reading cannot show. Option d is incorrect because a personal target speaks to intention rather than to physiologic depletion. Deliberate loss on a weight management plan is a different finding from loss the client never sought.

Correct Answer: The red-brown streaks in a febrile client

Fine red-brown linear streaks in the nail bed are splinter haemorrhages. They usually follow trauma, but paired with fever they raise concern for infective endocarditis and warrant prompt provider notification. Option a is incorrect because white lines and spots in the plate are leukonychia striata, left by minor injury to the nail matrix. They are benign and are not a sign of calcium or zinc deficiency. Option b is incorrect because nail growth slows with age and produces longitudinal ridging, brittleness, and yellowing. Those changes are expected in an older adult and call for foot care advice rather than a referral. Option c is incorrect because a central longitudinal depression with transverse ridges on the thumb comes from repeatedly picking one's own cuticle. Stopping the habit resolves it, so no medical follow-up is required.

Correct Answer: It is an erosion and will not scar

Erosion is loss of epidermis only. Because the dermis is untouched, the base stays moist, does not bleed, and heals without a scar. A ruptured vesicle or bulla leaves exactly this. Option b is incorrect because an ulcer reaches into the dermis and beyond, where the vessels live, so it may bleed and always heals with a scar. Pressure and stasis wounds are typical. Option c is incorrect because fissures are linear cracks with abrupt edges that split down into the dermis, as at the corners of the mouth in cheilosis. Nothing here is crack shaped. Option d is incorrect because excoriation is self-inflicted, a linear or punctate abrasion gouged out by fingernails during intense itching. This client described a blister that opened, not a scratching habit.

Correct Answer: Watch the uncovered child, then attempt consoling

Legs and body must be uncovered and watched for at least a minute, with repositioning or touch to gauge body tension and an attempt to console. Consolability is one of the five scored categories. Option a is incorrect because sleep does not rule out pain, and an exhausted child sleeps despite it. Scoring only at rest also misses the leg drawing and rigidity that appear when the child is moved. Option c is incorrect because the score comes from the nurse's structured observation of five defined categories. A parent contributes priceless baseline detail about the child's usual behavior, yet assigning the number remains a nursing responsibility. Option d is incorrect because an unnamed score is meaningless later on. Scores compare only within one tool, so the chart entry must identify which instrument produced this number for this child.

Correct Answer: "What does the pain feel like to you?"

Character and quality is the one element that sorts mechanisms. Aching, throbbing, and cramping point to tissue, while burning, shooting, and electric descriptors point to nerve injury, and the answer decides the drug class. Option b is incorrect because duration tells the nurse whether this pain is recent or long standing. Both tissue pain and nerve pain can last months, so a timeline cannot settle which mechanism is at work. Option c is incorrect because a severity rating measures how much, never what kind. A client can report the same number for an arthritic knee and for a burning diabetic foot. Option d is incorrect because location narrows the anatomy and can reveal a nerve distribution, yet it stops short of naming the sensation. Pinpointing a spot still leaves the nurse guessing between aching and burning.

Correct Answer: Kwashiorkor with relative protein deficiency

Bilateral pitting edema with an enlarged fatty liver, flaky paint dermatosis and banded hair marks kwashiorkor, where protein falls short while calories are partly maintained and the swelling hides the true weight loss. Option a is incorrect because marasmus starves the child of calories and protein together, leaving skin and bones, an aged looking face and no swelling at all. Edema rules this diagnosis out. Option b is incorrect because rickets deforms growing bone, showing bowed legs, beading along the rib junctions, widened wrists and late fontanelle closure. Liver enlargement and peeling skin have no place in it. Option d is incorrect because a child short of vitamin C bleeds, with spongy gums, tender limbs from bleeding under the bone covering and pinpoint hemorrhages. Swollen legs and a big liver point elsewhere.